Provider Demographics
NPI:1851873285
Name:STEPHENSON, SAMANTHA SUZZANNE (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SUZZANNE
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 LILAC CT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373
Mailing Address - Country:US
Mailing Address - Phone:951-313-0683
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON STREET
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-01
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA643818163WP0200X
CA95010543363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics